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C I \ Cc o) 1l <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator C0 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and m ; <br /> located as shown herein.The undersigned agrees that all work shall be done in accordance with the requirements of the Bur- m m <br /> nett County Land Use Ordinance,Sanitation Code,and with all other applicable County Ordinances and the laws and regula- 3 0. <br /> tions of the State of Wisconsin. y <br /> ��/ �.t ♦ -J t.L� \. fel ` C <br /> 0 <br /> O. <br /> OWNER(Ple se Print) Contractor or Surveyor or Agent o 3E <br /> ress Address <br /> City,State,Zip Code City,State,Zip Code <br /> Telephone Telephone <br /> a �9 TDhn50n �pke I 76 <br /> Emergency/Fire No. and Road Name <br /> Legal Description (as indicated on tax statement) - <br /> J <br /> Permit(s)Applied for: 0 m <br /> O <br /> New Building Sanitary Filling/Grading Camping Unit = <br /> r <br /> Addition Privy Moving Subdivision o ° <br /> �Pc � " x / qI <br /> Z o <br /> Structure Use: ° o <br /> (family home/cabin, garage, type of addition,etc.) m <br /> Directions for plot plan drawing: <br /> 1.Show the location and size of all existing buildings(EB)and all new buildings(NB)and indicate North (N). r <br /> 2.Show the location of the well (W), septic tank(ST), and drainfield (DF). o <br /> 3.Show the location of any lake or flowage- if within 1000 ft. and the location of any river or stream -if within 300 ft. <br /> 4.Show dimensions in feet of the following:(a)building to all lot lines,(b)building to center line of road,(c)building to ordi- <br /> nary high water mark of lake, river or stream, if applicable. <br /> 5. If,separate plans are submitted by an architect,engineer, builder,contractor,etc.,the plans must be signed and dated by 0 <br /> the owner. c <br /> 3 <br /> o N <br /> PLOT PLAN r" G_ J� Z c <br /> o a <br /> N <br /> O <br /> n <br /> /N <br /> 72, <br /> cn <br /> /L' /`FVJCl1 <br /> v <br /> V � o <br /> /w = <br /> _ <br /> Z <br /> it <br /> I � <br /> (nvmrD 'O <br /> L ar ==-.aMa A <br /> 0 a d�yo . 3 <br /> N � H O = <br /> .. Z O <br /> N A M <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- o' 0 <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I : I <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this ap- <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have <br /> access to the above described premiseseat any reasonable time for the purpose of inspection. m <br /> m <br /> SIGN HERE - - <br /> (s—ig�n�pt�ure of <br /> owner oJfor) (da e)u <br /> nffil�1Cft ZONING ADMINISTRATOR o o <br /> N m <br /> TOWNSHIP PERMITS MAY BE REQUIRED oococ�o m <br /> 0000 ogo <br />